Infusing TPN

[rileygrl11]

I remember all through school having it drilled into my head that TPN was to infuse by itself and never to piggyback ANYTHING else into it. Where I work RN's consistently piggyback numerous drugs into the TPN line. Most often it is antibiotics, pepcid, morphine and zofran/phenergan. I am currently searching for info on this from the internet, but in the mean time would like your input. Thanks!

[jnette, ASN, EMT-I]

Originally posted by ceecel.dee

WOW! I thought it was a lot more....I mean...way more!

I'm going to ask a friend in the office to show me what we charge!

MORE ??? M-O-R-E ....??????? Can it possibly be MORE?

[ceecel.dee, MSN, RN]

Originally posted by 3rdShiftGuy

Original response removed.

They do get infected, but usually those are the ones that stay in for way to long, like weeks on end.

Patients needing IV access for "weeks on end" are the indication for the central line, in many cases. Our infection rate remains nill.

[caroladybelle, BSN, RN]

Originally posted by P_RN

I guess this goes with beating a dead horse, but I still want to read the policy from the #1 cancer treatment center. Passing- thru where can it be found?

I would also like to know that info P_RN. As well as how it and by what organization it was so rated.

At Hospital of U of Penn - Bone Marrow Transplant unit:

As a general rule, most patients have at least a double or triple lumen access, or more than one CVAD access with multiple lumens each. The patients are extremely immunocompromised. I saw little to no line infection there, compared to many facilities. Nurses draw most labs from the CVAD. Lines that must be used for certain meds (TPN/Insulin/Heparin/Tacrolimus) are marked so that the measuring labs are not drawn from them. And if all possible, no other meds go through the TPN line. Blood cultures sometimes are one from the line and one peripherally, or both peripherally or both from line depending on MD orders.

PS. I believe HUP is where they discovered the "Philadelphia Chromesome" used in cancer diagnosis. I do not know it's numerical ranking on polls.

In a small "podunk" hospital in the Mtns of Georgia with a very dedicated nursing staff and a patient population that included multiple leukemic inductions and consolidations (very immunocompromised ca patients), I also noted few to no line infections. Line caps were changed with all blood draws and transfusions. Nurses drew most blood labs from the CVADs, excluding coags on heparin infusion patients, and peripherally ordered BCs. No masks were used when drawing blood. And if at all possible, no meds were permitted to go through the TPN line. If they had to, the PharmD was to authorize it on a daily basis.

The reason for the PharmD. needing to authorize meds going through the TPN line. The PharmD (doctor of pharmacy), in that facility ordered the TPN by reviewing the MD orders (regarding fluid restrictions/CHF issues) and the labs that indicate electrolyte needs. That means that on some patients, the contents of the TPN may vary widely from day to day. And what may be compatible one day, may not be compatible the next. And what may not cause precipitation one day, may do so on the next.

I have seen many drugs such as Primaxin, Ativan, and Phenergan precipitate in IV lines.

As far as MDs knowing that drugs are compatible, that would depend on where you are. I know some wonderful ones that had to be taught by Nurses that Ampho B and Dilantin are highly incompatible with anything. When we explained that Dilantin is very irritating to peripheral veins, and Cerebyx was preferred, they changed immediately. And judging from the number of HIV patients with pneumocysitis that have orders for fluid restrictions of 1L/24 hours to include IVs and Q6 hour Bactrim (500cc a bag) orders, many of them do not know how things are mixed. Also, each patient generally has several MDs, all in their own little speciality world, frequently unaware of the big picture.

As a Nurse, we are the ones administering the drugs, it is our responsibility to administer them correctly. We are also the ones that deal with the big picture.

"PER USUAL"

[gwenith, BSN, RN]

Caroladybelle once again you have written an eloquent and succinct post!

I agree whole heartedly with the point about teh doctors not knowing how to administer drugs. I have seen them insist on us giving all teh vitamins at once - teh burrette jellied!! Yup it didn't just interact it turnedto jelly!! Can't tell how many times I have stood next to the doctor with the "Drug administration" book showing how a drug is recommended to be given!!!

I guess because we are responsible for the administration we are more careful and try ot ensure that we do not mix drugs period.

[Tweety, BSN, RN]

Originally posted by ceecel.dee

Patients needing IV access for "weeks on end" are the indication for the central line, in many cases. Our infection rate remains nill.

I'm talking about patients who have theirs in 3 weeks or longer, who are generally very ill. I think that is a long time for a central line, but definately not unheard of.

I'd like to say our infection rate is nil, but that's just not true. But it is pleasantly low.

So what is the average life of a central line? I've always assumed it was for the short-term (several days to several weeks). That port-a-caths, Groshshongs, etc. and others for for the "weeks on end" people.

[gwenith, BSN, RN]

Tweety

http://www.joannabriggs.edu.au/pubs/cvl.php

You might find this helpful unfortunately I could not find anything on frequency of catheter changes. I have a feeling I have read a systematic review on it though - maybe the Cochrane database??

[caroladybelle, BSN, RN]

As a matter of note.

All CVADs should have a blood return. If they do not, frequently it means that either they are not in the right place (and should be replaced/or repositioned by MD), or fibrin sheathes/clots have formed. In addition, ports develop "sludge" in them. If you ever see one removed, they have really nasty looking crud in them.

All of these predispose the patient to develop line sepsis, despite good technique. Bacteria in the body or introduced from the line will feed on the clot/fibrin/sludge. Also the clots/fibrin irritate surrounding tissues, predisposing them to more clots and complications.

As such, if lines do not draw blood return, and placement has been confirmed by IR, they should be declotted if possible, to decrease risk of complications. This is the policy of the Oncology Nurses Society. As well as chemo (especially vesicants/irritants) should never be given through a line that has no blood return.

Some surgeons are notorious for placing lines that do not have return. And others are almost perfect in their placement and usefulness. It can be very difficult to get them to use better technique. Fortunately, I have been fortunate to work with Oncos that require good technique/placement and refuse to work with surgeons that have poor technique. The Oncos are adament about excellent care for their patients and that they not be stuck more than absolutely necessary and that risk of infection and complications are minimized.

[nowplayingEDRN]

Check out these links that I used when developing my CVAD inservice.

http://www.meditheses.com/997-962.htm

http://www.nursingcenter.com/prodev/ce_article.asp?tid=260258

http://www.nursing-standard.co.uk/archives/vol14-43/pdfs/4550w43.pdf

I hope that these provide some good valuable info for folks to use and incorporate into their practice combined with the follwing of their individual facility's SOPs.

[Tweety, BSN, RN]

Thanks Gwenith for the interesting link. But I was asking how long the line itself should stay in.

According to an article in UntamedSpirit the untunneled lines CVAD lines, which is what I'm talking about, no standard has been set as to how long they stay in.

But from my experience, the longer they are in, the higher the risk of infection, which is kind of like "well duh...of course".

Just was curious how long is too long.

[NRSKarenRN, BSN, RN]

Had homecare patient with triple lument CVP in for ONE YEAR before we could find a doc willing to replace it. Only two RN's did the dressing changes , no infection. Rule of thumb in Philly area is to get non-tunneled caths replaced q 2-3 months for home infusion patients.

[nowplayingEDRN]

Originally posted by 3rdShiftGuy

Thanks Gwenith for the interesting link. But I was asking how long the line itself should stay in.

According to an article in UntamedSpirit the untunneled lines CVAD lines, which is what I'm talking about, no standard has been set as to how long they stay in.

But from my experience, the longer they are in, the higher the risk of infection, which is kind of like "well duh...of course".

Just was curious how long is too long.

I know I have read something about dwell time recommendations, as Gwenith has mentioned. Now, the problem is remembering where I read it. I am either: A) getting old, B) developing Alzheimers at an early age or C) just plain suffering from CRS syndrome!!!

[New CCU RN]

Originally posted by P_RN

I guess this goes with beating a dead horse, but I still want to read the policy from the #1 cancer treatment center. Passing- thru where can it be found?

Passing thru.........why dont you pass on through and answer everyone's question???? Please enlighten those of us not fortunate enough to be employees of a world class hospital.